Epilepsy causes disadvantage for many reasons, and for women there are particular problems associated with epilepsy in pregnancy. Some are the direct result of seizures, some result from the drug treatment, and some are secondary handicaps because of stigmatisation. It was not very many generations ago that women with epilepsy were routinely advised not to reproduce, and in many countries, even in recent times, there have been legal interdictions on marriage and childbearing. In the western democracies, less prejudicial attitudes now prevail, but recent epidemiological evidence still shows that women with epilepsy, when compared to controls, have lower fertility rates,¹ children born later, lower rates of marriage,² higher rates of sexual dysfunction,³ and hormonal changes.⁴ There are currently about 75 000 women of childbearing age on treatment for epilepsy in the UK,¹ and about 0.3-0.4% of all births are to mothers with epilepsy. The neurologist has a duty to provide information and advice on many issues relating to the management of epilepsy in pregnancy, an increasing imperative as these issues have become the focus of much public interest. A key to all decision making is that the women should be fully involved and informed about the choices, and decisions made after full discussion.

Ideally the issues relating to epilepsy and pregnancy should be brought up well in advance of any planned pregnancy to allow informed and well considered choices. In preconceptional counselling, it is first necessary to decide whether treatment is indicated at all. This will depend on an assessment of the balance of risks of drug treatment versus those of the untreated epilepsy. A decision to withhold treatment might be made, for instance in some patients with minor seizures, reflex seizures, seizures at night, or infrequent seizures. Rules are not …